The likelihood of rupture of unruptured intracranial aneurysms that were less than 10 mm in diameter was exceedingly low among patients in group 1 and was substantially higher among those in group 2. The risk of morbidity and mortality related to surgery greatly exceeded the 7.5-year risk of rupture among patients in group 1 with unruptured intracranial aneurysms smaller than 10 mm in diameter.

Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Objectives: The objective was to evaluate the cost-effectiveness of dexamethasone versus prednisone for the treatment of pediatric asthma exacerbations in the emergency department (ED).Methods: This was a cost-effectiveness analysis using a decision analysis model to compare two oral steroid options for pediatric asthma patients: 5 days of oral prednisone and 2 days of oral dexamethasone (with two dispensing possibilities: either a prescription for the second dose or the second dose dispensed at the time of ED discharge). Using estimates from published studies for rates of prescription filling, compliance, and steroid efficacy, the projected rates of ED relapse visits, hospitalizations within 7 to 10 days of the sentinel ED visit, direct costs, and indirect costs between the two arms were compared.Results: The rate of return to the ED per 100 patients within 7 to 10 days of the sentinel ED visit for the prednisone arm was 12, for the dexamethasone ⁄ prescription arm was 10, and for the dexamethasone ⁄ dispense arm was 8. Rates of hospitalization per 100 patients were 2.8, 2.4, and 1.9, respectively. Direct costs per 100 patients for each arm were $20,500, $17,200, and $13,900, respectively. Including indirect costs related to missed parental work, total costs per 100 patients were $22,000, $18,500, and $15,000, respectively. Total cost savings per 100 patients for the dexamethasone ⁄ prescription arm compared to the prednisone arm was $3,500 and for the dexamethasone ⁄ dispense arm compared to the prednisone arm was $7,000.Conclusions: This decision analysis model illustrates that use of 2 days of dexamethasone instead of 5 days of prednisone at the time of ED visit for asthma leads to a decreased number of ED visits and hospital admissions within 7 to 10 days of the sentinel ED visit and provides cost savings. ACADEMIC EMERGENCY MEDICINE 2012; 19:943-948 ª 2012 by the Society for Academic Emergency MedicineA sthma is the most common chronic condition affecting children and a prominent chief complaint in pediatric emergency departments (EDs).1 Current standard of care in the ED includes systemic steroids for those patients who fail to respond promptly or completely to short-acting beta-agonist therapy.2 Systemic steroids have been shown to reduce airway inflammation, decrease rates of hospitalization, and decrease the number of repeat visits to the ED. [3][4][5][6] Traditionally, the most commonly prescribed systemic steroid regimen is a 5-day burst of oral prednisone ⁄ prednisolone. 4,5,7 However, several recent studies have shown that a 2-day course of dexamethasone has comparable efficacy to a 5-day course of prednisone ⁄ prednisolone for acute asthma management. 3,6,8,9 Compliance with oral systemic steroids after ED discharge is often a challenge for patients and families. 10Factors contributing to poor compliance include prolonged course of therapy, socioeconomic factors, underappreciation of severity of symptoms, and concern about medication side effects. 3,[10][11][12] Dexamethasone is an attract...

BACKGROUND:Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations.METHODS:This was an online anonymous survey of a random sample of EM health providers in US EDs.RESULTS:Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended.CONCLUSIONS:This is the first cross-sectional survey to provide “real-world” data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.